Chest pain presenting to the Emergency Department—to stratify risk with GRACE or TIMI?

doi:10.1016/j.resuscitation.2006.11.023

Resuscitation

Volume 74, Issue 1, July 2007, Pages 90-93

https://doi.org/10.1016/j.resuscitation.2006.11.023 Get rights and content

Summary

Introduction

There is a need to stratify risk rapidly in patients presenting to the Emergency Department (ED) with undifferentiated chest pain. The Global Registry of Acute Coronary Events (GRACE) and the Thrombolysis in Myocardial Infarction (TIMI) scoring systems predict outcome of adverse coronary events in patients admitted to specialist cardiac units. This study evaluates the relationship between GRACE score and outcome in patients presenting to the ED with undifferentiated chest pain and establishes whether GRACE is preferential to TIMI in stratifying risk in patients in the ED setting.

Materials and methods

Descriptive study of a consecutive sample of 1000 ED patients with undifferentiated chest pain presenting to Edinburgh Royal Infirmary, Scotland. GRACE and TIMI scores were calculated for each patient and outcomes noted at 30 days. Outcomes included ST and non-ST myocardial infarction, cardiac arrest, revascularisation, unstable angina with myocardial damage and all cause mortality at 30 days. Score and outcome were compared using receiver operator characteristic curves (AUC-ROC).

Results

The GRACE score stratifies risk accurately in patients presenting to the ED with undifferentiated chest pain (AUC-ROC 0.80 (95% CI 0.75–0.85), see Table 1). The TIMI score was found to be similarly accurate in stratifying risk in the study cohort with an AUC-ROC of 0.79 (95% CI 0.74–0.85). It was only possible to calculate a complete GRACE score in 76% (n = 760) cases as not all the data variables were measured routinely in the ED.

Conclusions

GRACE and TIMI are both effective in accurately stratifying risk in patients presenting to the ED with undifferentiated chest pain. The GRACE score is more complex than the TIMI score and in the ED setting TIMI may be the preferred scoring method.

Introduction

Patients presenting with undifferentiated chest pain account for a significant proportion of the Emergency Department (ED) workload. An accurate and reliable method of stratifying risk in these patients is therefore required to determine which patients are at higher risk of significant cardiac events. The Global Registry of Acute Coronary Events (GRACE)1, 2 and the Thrombolysis in Myocardial Infarction (TIMI)³ working groups have devised scoring systems to predict outcome in patients presenting with a presumed diagnosis of acute coronary syndrome. The aims of this study were to evaluate the relationship between the GRACE score and outcome in patients presenting with undifferentiated chest pain and establish whether GRACE is preferential to TIMI in stratifying risk in patients in the ED setting.

Section snippets

Materials and methods

The study took place in the Emergency Department of Edinburgh Royal Infirmary, Scotland—a city-centre teaching hospital with approximately 85,000 adult attendances per year. One thousand consecutive patients presenting with chest pain were enrolled into the study over a 2-month period. Epidemiological data were collected for each patient. TIMI and GRACE scores were not calculated from the outset. Exclusion criteria were age under 20 years or where the assessing clinician judged the pain to be

Results

The 1000 eligible patients were recruited over 75 days. Data was available for complete GRACE scoring in 760 cases. The majority (n = 161, 16% of sample, 75% of excluded patients) of exclusions were due to unavailability of creatinine estimation. Twenty-six patients were excluded as outcome data was incomplete. Thirty-two patients had an MI or troponin positive ACS at presentation and were deemed not to have achieved a positive outcome unless they had a subsequent event. The median age was 68

Discussion

This study presents the first analysis and comparison of the GRACE and TIMI scoring systems in an ED chest pain population. Both scoring systems have been shown to have a similar sensitivity and specificity in predicting outcome for patients presenting with chest pain of presumed cardiac origin.1, 3 The value of using the TIMI score to stratify risk in patients with undifferentiated chest pain in the ED setting has been established.⁴ In this study, we have shown that the GRACE score stratifies

Conclusions

Further prognostic research is warranted to evaluate the efficacy and practicality of each score, particularly in the ED setting, together with determining the importance of measuring presentation cardiac markers.

In conclusion, both the TIMI and GRACE have the potential to stratify risk in patients presenting to the ED with undifferentiated chest pain accurately. The GRACE score is more complex than the TIMI score and in the ED setting TIMI may be the preferred scoring method.

Conflict of interest

None declared. The need for formal ethical approval was waived by the local Ethics Committee.

Acknowledgments

The authors would like to thank Dr. A. Flapan and Dr. D. Bell for allowing access to in-patient information.

References (4)

The GRACE Investigators
Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes
Am Heart J
(2001)
K.A. Eagle et al.
A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry
JAMA
(2004)

There are more references available in the full text version of this article.

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The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients
2021, International Journal of Cardiology
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These objective risk scores were designed to identify those suitable for safe discharge among low-risk patients, or to discriminate low-risk from high-risk patients. Although the Global Registry of Acute Coronary Events (GRACE) [8] and Thrombolysis in Myocardial Infarction (TIMI) [9] risk scores were not specifically developed for the ED setting, both have successfully been evaluated as ED-based accelerated diagnostic protocols (ADPs) [10–12]. In contrast, the five-parameter History, ECG, Age, Risk Factors and Troponin (HEART) score was developed specifically for the ED setting [13].
Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients.
A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures.
Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2–97.6%) and 97.2% (95%CI 93.2–98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8–85.2%) and 53.9% (95%CI 46.2–61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68–0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge.
The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.
Can a HEART Pathway Improve Safety and Diagnostic Efficiency for Patients With Chest Pain?
2019, Annals of Emergency Medicine
HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis
2019, Annals of Emergency Medicine
Citation Excerpt :
For the HEART score to be used clinically, these results suggest that future work should target the modified HEART score, high-sensitivity troponins, or both. In recent years, multiple chest pain risk-stratification scoring systems (eg, Thrombolysis in Myocardial Infarction, Global Registry of Acute Coronary Events) have been derived and validated in different studies.6-8 However, most scoring systems are intended to evaluate short-term outcomes, such as mortality or recurrence of myocardial infarction, among hospitalized chest pain patients with history of coronary artery disease.
The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post–ED-discharge patient follow-up intervals.
We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.
There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non–low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).
In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.
Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes
2018, Annals of Emergency Medicine
Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study
2018, Annals of Emergency Medicine
Citation Excerpt :
We know relatively little about how emergency physicians make decisions in situations in which there is a low probability of disease but significant potential for bad consequences if disease is not diagnosed. Decision instruments might provide help, but risk-scoring systems for chest pain such as ACI-TIPI, TIMI, GRACE, HEART, and attribute matching are not sensitive enough to completely exclude acute coronary syndrome in the ED setting.2,12-17 For example, the lowest possible score in the TIMI scoring scheme, 0, corresponds to a 5% risk of the combined endpoint of myocardial infarction, revascularization, or death at 14 days, and a score of 0 to 3 on the HEART scale can be associated with as high as a 1.7% chance of a bad outcome within 6 weeks.
We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low-risk chest pain.
We created a Web-based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin-level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3-item Fear of Malpractice scale.
Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety-five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms “very low risk” and “low risk” only when their probability estimates were less than 1%.
The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.
Impact of implementation of the HEART pathway using an electronic clinical decision support tool in a community hospital setting
2018, American Journal of Emergency Medicine

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.11.023.

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Clinical paperChest pain presenting to the Emergency Department—to stratify risk with GRACE or TIMI?☆

Summary

Introduction

Materials and methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Conflict of interest

Acknowledgments

Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes

Am Heart J

A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry

JAMA

Clinical paper
Chest pain presenting to the Emergency Department—to stratify risk with GRACE or TIMI?☆